Physicians in the Nineteenth Century Ottoman Empire

A review of The Foundation of a Professional Group: Physicians in the Nineteenth Century Modernizing Century Modernizing Ottoman Empire (1839-1908), by Ceren Gülser İlikan Rasimoğlu.

Much of the historiography of nineteenth century reforms in the Ottoman Empire reads like a permanent break away from modernization theory. This tendency has shown a preoccupation among historians, for the last thirty-odd years, to move away from the writing of the Tanzimat (Ottoman reforms) in the 1940s-1960s, as well as from the philosophy of history adopted by the reformers themselves. A growing group of historians of the late Ottoman period, Ceren İlikan Rasimoğlu among them, is making that argument from the perspective of the history of health and medicine.

Modernization theory in the realm of medicine meant an epistemological transition to new formats of scientific knowledge (biochemistry, bacteriology, and Pastorian vaccines) and an overall improvement of sanitary standards, through vaccination, sanitation, and public health. But it had wider social and political implications, meaning that modernization moved in space through diffusion, in society through the top-down implementation of professional norms and the making of a medical profession, in sharp contrast with whatever medical practice existed before. Modernization thus stands out as a self-serving intellectual trap, a triumphalist reading of medicine that highlights the role and deeds of physicians as a new profession for the common good. Much academic literature has been devoted to debunking this notion, which erases the continuities before and after “modernization,” the multiplicity of actors and the changing directions of the process. İlikan Rasimoğlu’s question could be summarized as follows: if medical reform cannot be analyzed through the faulty paradigm of modernization, then what was it?

Her answer is to present medical reform as a vast reorganization of medical practice around three processes: standardization, professionalization, and politicization (p. 2). These processes followed different chronologies, far from linear, the coherence of which lay in a common trend towards the joint production of a state and a population. In this, she walks in the steps of historians of medicine such as Roy Porter, and shares the Foucauldian inspiration of David Arnold, whose work on medicine and public health in colonial India highlighted the disciplinary, exclusive, and integrative nature of medicine through institutions.

What stands out, though, after reading her work, is somewhat different. She analyses a great many cases of conflicts about legitimacy in the practice of medicine, about enforcing quarantine, or about attempts to hide “bad books” from the intrusive gaze of the police of sultan Abdül Hamid II. The picture that emerges owes more to another Foucauldian notion at work in a period of reorganization, that of the “microphysics of power.” She tackles specifically the respective effects on the ground of centralized attempts to dictate the conditions of the practice of medicine, of internationally devised mechanisms to control people’s mobility and thus the agency of micro-organisms through them, and of efforts by the sovereign to control public debate.

The author’s bibliography sheds further light on her take on the subject. Most of it focuses on the role of the central state and the limits of its agency at a local level. With this idea in mind, it is easier to understand the bibliography’s orientation toward a comparison with contemporary processes in Europe and North America, as it was where Ottoman reformers drew their inspiration from when devising medical reforms. These comparisons enable us to better envisage how the men of the Tanzimat period understood the reforms of the medical profession that they were implementing. They establish a dialogue between the reformers and their models.

However, a whole body of literature, that of the history of colonial medicine, is largely cast aside, which in itself hints at an underlying interpretive hypothesis, to wit: medical reform was about state building rather than (self-)colonization. The choice of a bibliography focusing on Ottoman history and Western medical history takes, rightly, the forceful and at times plainly violent character of the imposition of Ottoman medical reforms to be a general feature of state-driven medical reforms. İlikan Rasimoğlu makes a convincing case when she argues that many characteristics of the reform process obeyed logics that built up the modern nation state as much as the medical profession. This is relevant regarding the drawing of professional borders, the mobilization of medical graduates to people an understaffed provincial medical administration, or the ethnicization of professional recruitment, with the advent of an increasingly Muslim Turkish medical profession in the early twentieth century.

Yet, if we take in consideration linguistic features and the resulting estrangement between physicians and the communities they were sent to, or the attempts on the part of physicians themselves and their professional organizations, to make a vertical pattern of relations with the patients prevail, we may find relevance in the analysis of medical reforms as a colonial phenomenon, at least in parts of the empire. An indicator here would be the characterization of physicians as strangers in non-Turkish provinces, or the intervention of physicians in public debate to denounce national discriminations—and the latter case indeed grew increasingly frequent in the years leading up to the Great war.

This is not a clean-cut issue, and mechanisms inherent to the workings of the state often provide a sufficient explanation for the tensions related with the “modernization” process. Part of the desire not to dwell too much on geographical differences stems from a commendable intent to avoid the kind of ethnicization of medicine which, as she reminds us in Chapter 1, have produced an Orientalist medical history of the Ottoman Empire (p. 9). The chapter therefore avoids presenting medical reform as a set of cultural transfers from Europe, but rather shows the multi-facetted nature of reformed medicine. The chapter deals with the origins of Ottoman medical reforms and their broad chronology, and underlines the centrality of the Medical Code of 1861, which imposes the possession of a medical degree to practice medicine as a “doctor,” in the standardization of the medical profession (p. 12). However, several processes produce this standardization. They imply in particular a specific definition of crime in the medical field and of malpractice, and hence, of individual and political responsibility of the physicians before the patients but more generally before society, as well as training in deontology, which was part and parcel of the politicization of the medical students (pp. 12-13). Part of the construction of the medical profession is the use and increased imports of medical instruments, and the microscope and later the X-rays played an important part in shaping modern medical practices and common professional values (pp. 14-15). The author also links the institutional reorganization of the profession and the rise of public health as a state project that involves all Ottoman physicians (pp. 19-20). Through public health, modern physicians develop discourses on public interest, which are a significant part of their “professionalization” (pp. 22-23).

Chapter 2 analyses professionalization and the standardization of medicine. Professionalization is defined by the making of a group through the existence of a professional ideal and a common professional identity, before the drawing of professional boundaries by the physicians or for them, by the central state (p. 26). The whole chapter, however, presents a less straightforward process, because the production of profession ideals and norms on the one hand, and the making of boundaries on the other, are connected and dialectical processes. The starting point is that medicine before the reforms was organized, with strict professional norms and regulators, the judge (kadi) or the comptroller of the markets and professions (mühtesib) (p. 27) and organized training (p. 56). The control of the medical profession was, however, of a largely local nature, and earlier Ottoman institutions of training, founded around the sixteenth century, had largely been replaced by local or family networks of medical training (pp. 27-29). Altering this situation and centralizing control was the main project behind the 1861 Medical Code, but post-1861 developments show that traditional or long-established practitioners could often negotiate locally the right to practice medicine. At the same time, this negotiation was probably made easier by the reluctance of medical students towards certain aspect of their training, in particular autopsies.

Practitioners were not the only target of standardization processes. So were the patients and individuals in society in general (pp. 30-34), whose disciplinarization worked through medical institutions and their organizations. Hospitals were a salient feature in this process, although what it is exactly in their conception and internal order that is of a disciplinary nature is not crystal-clear here (p. 44). Indeed, there was a distance between general medical and disciplinary principles, and the decisions of the medical authorities regarding the conception of hospitals, which not infrequently went against the then-popular ideas of aerism, for instance (p. 47).

From there, İlikan Rasimoğlu establishes the chronology of the modern medical faculties (pp. 57-66) and the progressive institutionalization of the medical profession through successive regulations of the Tanzimat era, until the eventual foundation of a ministry of health in the Republican era (p. 66-67). Yet this legal organization of the profession is not sufficient to describe its mechanisms. Chapter 3 analyses these from below, through the study of informal practice (pp. 116-139). Between the successive regulations on the practice of medicine, and the chronology of complaints for illegal practice, or the informal arrangements between local powers and illegal practitioners (read: physicians without a diploma), was anything but linear, and knew certain accelerations, such as the period between the Medical Penal Code (1884) and new regulations of practice for physicians without an Ottoman diploma in 1888.

Chapter 4 focuses on training as a disciplinary process for the physicians and a breeding ground for collective action among physicians. One such collective action the organization of medical societies, which reflected religious and generational differences, as the Medical Imperial Society gathered French-trained and French-speaking physicians, while the rival and younger Ottoman Medical Society was founded later to promote Turkish as the language of Ottoman medical studies. The imposition of Turkish as the only language of study in Istanbul’s medical schools paved the way for a reduction of multilingual non-Muslims and an Islamization of medical practice (p. 173). The end of the chapter dwells on the political readings of the medical students and their game of hide-and-seek with the authorities and the sultan, who had much to fear from the oppositional politicization of students, especially because of their heterodox readings.

Chapter 5 examines the centralization of medical services and the insertion of physicians at the same time within a state public health structure and within a provincial context. Far from the triumphalist view of modern medicine, often written by physicians themselves, which claims that physicians brought indubitably better healthcare, this part of the thesis shows popular oppositions to newly-appointed physicians in the provinces. Some of those oppositions were motivated by religions, given the high proportion of non-Muslim medical graduates for most of the nineteenth century. Yet some of it also had to do with the bad reputation that these physicians, who lived their provincial positions as a form of exile, and were often absentee doctors. Linguistic factors also played a part, which went some way to explain the foundation of the Ottoman Medical School of Damascus, which the author, quoting an erroneous source, places in 1899 instead of 1903 (p. 227). Here, the history of the Arab University of Damascus (based on the Ottoman Medical School) by Abdul Karim Rafeq (in Arabic) would be a useful source and element of contextualization.

Chapter 6 analyses the organization of quarantine as yet another disciplinary mechanism—disciplinary for the travelers, first and foremost—which met with opposition. But through these oppositions, another authoritarian image of physicians builds up. The most original aspect of this study is the survey of land quarantines against cholera and the often violent oppositions they elicited (pp. 309-313). The presentation of the international system of quarantines, especially around the pilgrimage to Mecca, and the hardship that it entailed, especially in the quarantine station in Karaman is sketchier. At the same time, the theme is better known, as recent works (such as Sylvia Chiffoleau’s) have highlighted its authoritarian and quite colonial character, as well as the ambiguous roles played by physicians in this context: they were entrusted with heavy responsibilities and penalized if they failed to carry them out, and Ceren İlikan Rasimoğlu gives a few enlightening examples of sailors and passengers circumventing the quarantine (pp. 312-314) and being punished for it (p. 316). Yet recent research also shows that physicians played a significant role in the transformation of the quarantine system in the Ottoman domains, away from its worst excesses in the years going from the 1865 epidemic to the 1890s. Physicians played, first as witnesses on the spot, a significant part in this process of rearranging the disciplinary order of quarantines.

The thesis is supplemented with a few annexes, all of them transcripts or photographs of sources documenting the many petty or harsher conflicts which resulted from the wide scope of Ottoman reforms. This is an interesting documentation, and I could only wish for a systematic presentation of both the transcriptions and the original documents in every case.

To sum up, İlikan Rasimoğlu’s research is a valuable addition to our understanding of state medical reforms in the Ottoman Empire, and the limits of the state’s ability to enforce its own reforms in a uniform manner. The making of the modern medical profession in the Ottoman Empire was a pervasive phenomenon, the influence of which was reverberated outside its immediate field of competence in a variety of social dimensions of healthcare, and with multiple, often contradictory effects. It also was a vertical organization whose normative dynamics often met with conflicts. This verticality has not disappeared from many aspects of medical organization to this day, but has rather expanded with the multiplication of medical schools in the Middle East over the twentieth century and the development of the social and political functions of the physicians.

Primary sources:
Başbakanlık Osmanlı Arşivi (Prime Ministry Ottoman Archives), Istanbul.
Biographies and autobiographies of physicians, mostly from the Second consitutional period and the Republican era.